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56
METHUSELAH
In the US, the Veterans Affairs Diabetes
Trial previously showed that intensive
glucose-lowering, as compared with
standard therapy, did not significantly
reduce the rate of major cardiovascular
events among 1,797 military veterans
(median follow-up, 5.6 years). The trialists
now report on an extended follow-up.
The primary outcome sought was the time
to the first major cardiovascular event and
the secondary outcomes were cardiovascular
mortality and all-cause mortality. The
conclusions reached were that after nearly
10 years of follow-up, patients with type 2
diabetes who had been randomly assigned to
intensive glucose control for 5.6 years had
8.6 fewer major cardiovascular events per
1,000 persons-years than those assigned to
standard therapy, but no improvement was
seen in the rate of overall survival.
Methuselah
Primary prevention with lipid-lowering
drugs and long-term risk of vascular
events in older people
BMJ 2015; 350:h2335
Results from clinical trials show beneficial
effects of lipid-lowering drugs in the
primary or secondary prevention of
coronary heart disease and stroke in people
aged 50-70 years. This population-based
cohort study reviews the association between
use of lipid-lowering drugs (statin or fibrate)
in older people with no known history of
vascular events and long-term risk of coronary
heart disease and stroke.
7,484 men and women (63%) with a mean
age of 73.9 years and no history of vascular
events were followed for a mean follow-up
of 9.1 years. The findings were that use of
statins or fibrates was associated with a 30%
decrease in the incidence of stroke but had no
effect on coronary heart disease.
The authors of this study note that
the comparative efficacy and safety
of pharmacological agents to lower
blood pressure in adults with diabetes and
kidney disease remains controversial. Their
meta-analysis of relevant randomised
trials investigates the benefits and harms
of various blood pressure lowering drugs in
these patients. The primary outcomes were
all-cause mortality and end-stage kidney
disease.
157 studies comprising 43,256 participants,
mostly with type 2 diabetes and chronic
kidney disease, were included in the network
meta-analysis. No drug regimen was more
effective than placebo for reducing all-cause
mortality. However, compared with placebo,
end-stage renal disease was significantly
less likely after dual treatment with an
angiotensin-receptor blocker (ARB) and
an angiotensin-converting-enzyme (ACE)
inhibitor and after ARB monotherapy.
The researchers noted the benefits of the
ARB and ACE treatments need to be balanced
against potential harms of hyperkalaemia and
acute kidney injury. The analysis showed no
support for the use of beta blockers, calcium
channel blockers, renin inhibitors, or diuretic
monotherapy in the clinical trials.
Follow-up of glycemic control
and cardiovascular outcomes in
type 2 diabetes
NEMJ 2015; 372:2197-206
Efficacy and safety of blood pressure-
lowering agents in adults with
diabetes and kidney disease
Lancet 2015; 385:2047-56